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Showing results for "occur".

41. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events—errors that should never occur … A seminal study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, … It is worth noting, however, that many cases of WSPEs would still occur despite full adherence to the

42. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? | PSNet
    psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-procedure-and-wrong-patient-adverse-events-are-they-preventable
    February 24, 2011 - A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in … from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35927/psn-pdf
    February 17, 2011 - Healthcare Research and Quality–supported study discovered that claims without clear evidence of error do occur … On the other hand, the majority of expenditures toward litigation occur in cases of errors in which

44. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Approximately 8%-9% of adverse events occur in physicians’ offices.(1) Recent studies have examined … ordered annually in primary care practices, yet little is known about how often laboratory errors occur … Because of improvements in and automation of laboratory procedures, most laboratory errors occur during … This patient verification should occur at the time a specimen is labeled, and the label should include … key issue is that outpatient clinics and labs should have methods to capture these errors when they occur

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - The systems approach holds that efforts to catch human errors before they occur or block them from causing … Active errors almost always involve frontline personnel and occur at the point of contact between a … In this construct, slips represent failures of schematic behaviors, or lapses in concentration, and occur … FMEA begins with identifying all the steps that must occur for a given process to occur.

46. "What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. | PSNet
    psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
    July 10, 2017 - Despite widespread efforts to improve health care safety, medical errors continue to occur. … psychology , including theories related to behavior and cognition , to understand why care failures occur

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45255/psn-pdf
    January 23, 2017 - Although most mistakes occur during the prescribing and transcribing stages, errors during the administration … process occur frequently as well.

48. Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review. | PSNet
    psnet.ahrq.gov/issue/medication-errors-related-computerized-provider-order-entry-systems-hospitals-and-how-they
    April 07, 2021 - persist with long-term use of CPOE systems, but future research should explore the types of errors that occur … , when they occur, and the system factors contributing to the errors.

49. Anatomy and pathophysiology of errors occurring in clinical radiology practice. | PSNet
    psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
    February 01, 2011 - Commentary Anatomy and pathophysiology of errors occurring in clinical radiology practice. Citation Text: Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. d…

50. Creating a safer health care system: finding the constraint. | PSNet
    psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
    February 24, 2011 - This theory asks the question of what should change, to what should it change, and how should change occur … Responses are framed with discussion of six thought processes that must occur at an organization for

51. Never Events | PSNet
    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - , in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur … However, when Never Events occur, they are devastating to patients and may indicate a fundamental safety … A 2013  study  estimated that more than 4000 surgical never events occur yearly in the United States.

52. Urine a Tough Position | PSNet
    psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - Approximately 8%-9% of adverse events occur in physicians’ offices.( 1 ) Recent studies have examined … are ordered annually in primary care practices, yet little is known about how often laboratory errors occur … Because of improvements in and automation of laboratory procedures, most laboratory errors occur during … This patient verification should occur at the time a specimen is labeled, and the label should include … key issue is that outpatient clinics and labs should have methods to capture these errors when they occur

53. Systems Approach | PSNet
    psnet.ahrq.gov/primer/systems-approach
    June 15, 2024 - The systems approach holds that efforts to catch human errors before they occur or block them from causing … Active errors almost always involve frontline personnel and occur at the point of contact between a human … In this construct, slips represent failures of schematic behaviors, or lapses in concentration, and occur … FMEA begins with identifying all the steps that must occur for a given process to occur.

54. The pursuit of perfection: hospitals take heightened actions to reduce adverse events. | PSNet
    psnet.ahrq.gov/issue/pursuit-perfection-hospitals-take-heightened-actions-reduce-adverse-events
    November 18, 2020 - June 10, 2018 Tapping front-line knowledge: identifying problems as they occur helps … September 27, 2016 When errors occur.

55. Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode. | PSNet
    psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large-scale-closed-loop
    September 01, 2016 - Although most mistakes occur during the prescribing and transcribing stages, errors during the administration … process occur frequently as well.

56. Looking for Meds in All the Wrong Places | PSNet
    psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
    June 16, 2021 - As a result, medication errors occur regularly in the ED, ranging from about 5.4 to 16.1 medication errors … also need to be aware of high-alert medications, which can have catastrophic consequences if errors occur … Mistakes with medications occur not because a clinician has been incompetent by making an error, but … their own risks for medication errors, it is important to acknowledge that medication errors generally occur … Medication errors generally occur as a result of system failures rather than faults produced by particular

57. Heed this warning! Don't miss important computer alerts. | PSNet
    psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
    May 07, 2018 - May 7, 2018 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing … June 16, 2019 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing

58. Claims, errors, and compensation payments in medical malpractice litigation. | PSNet
    psnet.ahrq.gov/issue/claims-errors-and-compensation-payments-medical-malpractice-litigation
    March 02, 2011 - Healthcare Research and Quality–supported study discovered that claims without clear evidence of error do occur … On the other hand, the majority of expenditures toward litigation occur in cases of errors in which compensation

59. Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery | PSNet
    psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
    September 15, 2024 - wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events —errors that should never occur … A seminal study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, … It is worth noting, however, that many cases of WSPEs would still occur despite full adherence to the

60. Simple mistakes, serious consequences: positive ID is no laughing matter. | PSNet
    psnet.ahrq.gov/issue/simple-mistakes-serious-consequences-positive-id-no-laughing-matter
    May 24, 2006 - This article discusses how misidentification can occur in the medical environment and provides several